Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Original Article
Corresponding Author:
Abbas Abbaszadeh
Address: Nursing and Midwifery College, Shahid Beheshti University of Medical Sciences, ValiAsr Street, Tehran,
Iran. P.O. Box: 1996835119
Email: aabaszadeh@sbmu.ac.ir
Tel: 98 21 88202520
Fax: 98 21 88202521
Abstract
One of the advanced nursing care procedures emphasized by nursing organizations around the world is patient or nursing
advocacy. In addition to illustrating the professional power of nursing, it helps to provide effective nursing care. The aim of the
present study was to explain the concept of patient advocacy from the perspective of Iranian clinical nurses.
This was a qualitative study that examined the viewpoint and experiences of 15 clinical nurses regarding patient advocacy in
nursing. The nurses worked in intensive care units (ICUs), coronary care units (CCUs), and emergency units. The study
participants were selected via purposeful sampling. The data was collected through semi-structured interviews and analyzed
using content analysis.
Data analysis showed that patient advocacy consisted of the two themes of empathy with the patient (including understanding,
being sympathetic with, and feeling close to the patient) and protecting the patients (including patient care, prioritization of
patients health, commitment to the completion of the care process, and protection of patients' rights).
The results of this study suggest that nurses must be empathetic toward and protective of their patients. The results of the
present study can be used in health care delivery, nursing education, and nursing management and planning systems to help
nurses accomplish their important role as patient advocates. It is necessary to further study the connections between patient
advocacy and empathy.
Page 2 of 8
J Med Ethics Hist Med 9:5 June, 2016 jmehm.tums.ac.ir Abbas Abbaszadeh et al.
were conducted from June 2012 until June 2013 to interview, and then, presented these classifications
collect the data; 3 interviews were repeated. The and codes to other members of the research team for
duration of the interviews was 25 to 75 minutes with evaluation. The codes which were not agreed upon
an average of 53.3 minutes. The location and the were discussed until achieving clarification and
duration of the interviews were selected by the consensus. To control the dependability of the data,
participants. The primary research questions the researcher retained the preliminary data, codes,
included: Can you please explain your relationship categories, and themes. To achieve transferability or
with the patient as a nurse? or What are your stability of the results, sampling was carried out with
responsibilities toward the patient as a nurse? great variety to contribute to the credibility of data.
Exploratory questions were also asked during the Ethical considerations
interviews to obtain the participants' experiences and This study and its ethical considerations were
opinions and to clarify their responses. Data approved by and the necessary permits were
collection and analysis were carried out obtained from the Research Deputy of Kerman
simultaneously. The interviews were recorded and, University of Medical Sciences, Kerman, Iran. All
in order to obtain a general understanding, were the participants were informed of the nature,
studied at least 3 times. The recordings were purpose, and method of the study, the researchers
transcribed verbatim. The obtained data were tasks, their rights, and possible risks (this was a safe
analyzed according to the following steps (28). study) by the first author. The confidentiality of the
1. In order to gain a general understanding of them, participants statements, and their right to choose to
the interviews were studied several times, and then, continue or leave the study was emphasized by the
they were transcribed verbatim. research team. All participants consented to the
2. The interview texts were divided into compact recording of the interviews, and after receiving the
semantic units. necessary information, they signed an informed
3. The compact semantic units were converted into consent form.
abstract terms and assigned a specific code.
4. The emerged codes were categorized based on Results
their differences and similarities into subclasses and In the present study, 15clinical nurses with an
classes. average work experience of 8 years and 3 months
5. The themes were extracted from the interviews. and mean age of 32.25 years were selected from
The research team found no new information of selected wards suitable to the larger study (Table 1).
relevance to their study in the data in the 15th The participants were selected from educational and
interview. This is interpreted as data saturation in non-educational hospitals in different provinces of
qualitative research, and thus, no more interviews Iran to gain an adequate variation in experiences and
were needed (29). perspectives of nurses regarding patient advocacy in
Trustworthiness nursing.
To assess the studys trustworthiness, Lincoln and
Gubas Evaluative Criteria and authenticity were Table 1. Characteristics of the study participants
used (30). Lincoln and Gubas Evaluative Criteria Characteristics Number
consist of 4 criteria including: Male 3
Gender
A-Credibility: It shows that the identification and Female 12
introduction of research participants are accurate. Married 7
B-Dependability: It shows that data remain stable Marital status
Single 8
over time and under different conditions. Bachelor 14
C-Conformability: It shows objectivity, that is, the Education level
Master 1
potential for congruence between different Coronary care
independent individuals on the accuracy, relevance, unit (CCU) 7
or meaning of the data.
Working unit Intensive care
D-Transferability: It shows the potential to 5
generalize the findings of the study (29). unit (ICU)
Authenticity is an additional criterion that shows the Emergency unit 3
extent to which researchers indicate a range of Nurse 8
realities fairly and faithfully (31). Head nurse 3
Position
Due to the prolonged and continuous engagement of Supervisor 3
the researcher with the data, the participants, and Nursing manager 1
member checking, the credibility of the study
increased. For this purpose, the researcher gave a Interesting results were obtained from content
typed summery of the interviews to the participants, analysis. According to the participants statements,
so they could confirm his interpretations. In order to patient advocacy included the two themes of
meet the confirmability of the data, peer check was empathy with the patient and protecting the patient
used. The researcher first coded and classified each (Table 2).
Page 3 of 8
J Med Ethics Hist Med 9:5 June, 2016 jmehm.tums.ac.ir Abbas Abbaszadeh et al.
Page 4 of 8
J Med Ethics Hist Med 9:5 June, 2016 jmehm.tums.ac.ir Abbas Abbaszadeh et al.
Page 5 of 8
J Med Ethics Hist Med 9:5 June, 2016 jmehm.tums.ac.ir Abbas Abbaszadeh et al.
Page 6 of 8
J Med Ethics Hist Med 9:5 June, 2016 jmehm.tums.ac.ir Abbas Abbaszadeh et al.
References
1. Hanks RG. The lived experience of nursing advocacy. Nurs Ethics 2008; 15(4): 468-77.
2. Selanders LC, Crane PC. The voice of Florence Nightingale on advocacy. Online J Issues Nurs 2012; 17(1): 1.
3. Kalaitzidis E, Jewell P. The concept of advocacy in nursing: a critical analysis. Health Care Manag (Frederick) 2015;
34(4): 308-15.
4. Johnstone MJ. Nursing and justice as a basic human need. Nurs Philos 2011; 12(1): 34-44.
5. Zomorodi M, Foley BJ. The nature of advocacy vs. paternalism in nursing: clarifying the thin line. J Adv Nurs 2009;
65(8): 1746-52.
6. Roush K. Speaking out on social justice. Am J Nurs 2011; 111(8): 11.
7. Goodman T. The future of nursing: an opportunity for advocacy. AORN J 2014; 99(6): 668-71.
8. Maryland M, Gonzalez R. Patient advocacy in the community and legislative arenas. Online J Issues Nurs 2012; 17(1):
2.
9. Barlem JG, Lunardi VL, Barlem EL, Ramos AM, Figueira AB, Fornari NC. Nursing beliefs and actions in exercising
patient advocacy in a hospital context. Rev Esc Enferm USP 2015; 49(5): 811-8.[in Portuguese]
10. Hanks RG. Development and testing of an instrument to measure protective nursing advocacy. Nurs Ethics 2010; 17(2):
255-67.
11. Josse-Eklund A, Jossebo M, Sandin-BojAK, Wilde-Larsson B, Petzll K. Swedish nurses' perceptions of influencers on
patient advocacy: a phenomenographic study. Nurs Ethics 2014; 21(6): 673-83.
12. Ware LJ, Bruckenthal P, Davis GC, O'Conner-Von SK. Factors that influence patient advocacy by pain management
nurses: results of the American society for pain management nursing survey. Pain Manag Nurs 2011; 12(1): 25-32.
13. Negarandeh R, Oskouie F, Ahmadi F, Nikravesh M. The meaning of patient advocacy for Iranian nurses. Nurs Ethics
2008; 15(4): 457-67.
14. Gilkey MB, Earp JA. Defining patient advocacy in the post-quality chasm era. N C Med J 2009; 70(2): 120-4.
15. Atashzadeh Shorideh F, Ashktorab T, Yaghmaei F. Iranian intensive care unit nurses' moral distress: a content analysis.
Nurs Ethics 2012; 19(4): 464-78.
16. Flodn A, Lennerling A, Fridh I, Rizell M, Forsberg A. Development and psychometric evaluation of the instrument:
attitudes towards organ donor advocacy scale (ATODAS). Open Nurs J 2011; 5: 65-73.
17. Schlairet MC, Kiser K, Norris S. Clinical ethics support services: an evolving model. Nurs Outlook 2012; 60(5): 309-15.
18. Haylock PJ. Cancer survivorship advocacy. Semin Oncol Nurs 2015; 31(1): 79-85.
19. Mahlin M. Individual patient advocacy, collective responsibility and activism within professional nursing associations.
Nurs Ethics 2010; 17(2): 247-54.
20. Grady C, Edgerly M. Science, technology, and innovation: nursing responsibilities in clinical research. Nurs Clin North
Am 2009; 44(4): 471-81.
21. Spence K. Ethical advocacy based on caring: a model for neonatal and paediatric nurses. J Paediatr Child Health 2011;
47(9): 642-5.
22. Paquin SO. Social justice advocacy in nursing: what is it? How do we get there? Creat Nurs 2011; 17(2): 63-7.
23. Barlem ELD, Lunardi VL, Tomaschewski JG, Lunardi GL, Lunardi Filho WD, Schwonke CR. Moral distress:
challenges for an autonomous nursing professional practice. Rev Esc Enferm USP 2013; 47(2): 506-10.
24. Jafari Manesh H, Zagheri Tafhreshi M, Ashktorab T, Alavi Majd H. The comparison among perspectives of doctors,
nurses and patients towards patient advocacy role. J Shahid Beheshti Sch Nurs Midwif 2012; 22(76): 53-62. [in Persian]
25. Moretti F, van Vliet L, Bensing J, et al. A standardized approach to qualitative content analysis of focus group
discussions from different countries. Patient Educ Couns 2011; 82(3): 420-8.
26. Young S. Professional relationships and power dynamics between urban community-based nurses and social work case
managers: advocacy in action. Prof Case Manag 2009; 14(6): 312-20.
27. Elo S, Kyngs H. The qualitative content analysis process. J Adv Nurs 2008; 62(1): 107-15.
28. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to
achieve trustworthiness. Nurse Educ Today 2004; 24(2): 105-12.
29. Holloway I, Wheeler S. Qualitative Research in Nursing and Healthcare, 3rd ed. John Wiley & Sons; 2013, p. 25-100.
30. Lincoln YS, Guba EG. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Dir Program
Eval 1986; 1986(30): 73-84.
31. Elo S, Kriinen M, Kanste O, Plkki T, Utriainen K, Kyngs H. Qualitative content analysis a focus on
trustworthiness. SAGE Open 2014; 4(1): 1-10.
32. Hanks RG. The medical-surgical nurse perspective of advocate role. Nurs Forum 2010; 45(2): 97-107.
33. Crawford-Jakubiak JE. Advocacy opportunities for pediatricians caring for maltreated children. Pediatr Clin North Am
2014; 61(5):1073-83.
34. Keeshin BR, Dubowitz H. Childhood neglect: the role of the paediatrician. Paediatr Child Health 2013; 18(8): e39-43.
35. Emrich IA, Frhlich-Guzelsoy L, Bruns F, Friedrich B, Frewer A. Clinical ethics and patient advocacy: the power of
communication in health care. HEC Forum 2014; 26(2): 111-24.
36. Parkin T, de Looy A, Farrand P. Greater professional empathy leads to higher agreement about decisions made in the
consultation. Patient Educ Couns 2014; 96(2): 144-50.
37. Mennenga HA, Bassett S, Pasquariello L. Empathy development through case study and simulation. Nurse Educ 2016;
41(3): 139-42.
38. Bikker AP, Fitzpatrick B, Murphy D, Mercer SW. Measuring empathic, person-centred communication in primary care
nurses: validity and reliability of the Consultation and Relational Empathy (CARE) Measure. BMC Fam Pract 2015;
16(1):149.
Page 7 of 8
J Med Ethics Hist Med 9:5 June, 2016 jmehm.tums.ac.ir Abbas Abbaszadeh et al.
39. Bry K, Bry M, Hentz E, et al. Communication skills training enhances nurses' ability to respond with empathy to parents'
emotions in a neonatal intensive care unit. Acta Paediatr 2015; 105(4): 397-406.
40. Ferri P, Guerra E, Marcheselli L, Cunico L, Di Lorenzo R. Empathy and burnout: an analytic cross-sectional study
among nurses and nursing students. Acta Biomed 2015; 86(Suppl 2): 104-15.
Page 8 of 8